a nurse is assessing a patient with schizophrenia who is experiencing delusions which intervention is most appropriate a nurse is assessing a patient with schizophrenia who is experiencing delusions which intervention is most appropriate
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Nursing Elites

ATI RN

ATI Mental Health Practice A

1. A nurse is assessing a patient with schizophrenia who is experiencing delusions. Which intervention is most appropriate?

Correct answer: C

Rationale: The most appropriate intervention when assessing a patient with schizophrenia experiencing delusions is to engage the patient in reality-based activities. This intervention helps distract the patient from the delusions and reorients them to the present, promoting grounding in reality. Choice A is incorrect because agreeing with delusions can reinforce them and hinder treatment. Choice B may exacerbate the delusions by delving deeper into their basis. Choice D may not be beneficial as it focuses solely on the delusions without addressing the need to ground the patient in reality.

2. A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse implement? Select one that does not apply.

Correct answer: D

Rationale: Interventions for a client with bipolar disorder experiencing a depressive episode include encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discussing feelings is an essential part of therapy for clients with bipolar disorder, thus discouraging verbalization of feelings is not therapeutic and should not be implemented. Choice D is incorrect because it goes against the principles of therapeutic communication and emotional expression, which are crucial in managing bipolar disorder.

3. A patient with a history of breast cancer is being prescribed tamoxifen (Nolvadex). What should the nurse include in the patient education?

Correct answer: A

Rationale: The correct answer is A. Tamoxifen increases the risk of venous thromboembolism. Patients should be educated about signs and symptoms of blood clots, such as swelling, pain, or redness in the legs. Choices B, C, and D are incorrect because tamoxifen is not associated with decreasing the risk of osteoporosis, causing hot flashes and menopausal symptoms, or causing weight gain and fluid retention.

4. A nurse is caring for a client who is receiving enteral nutrition via a nasogastric tube. Which of the following actions should the nurse take to reduce the risk of aspiration?

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration in clients receiving enteral feedings is to elevate the head of the bed during feedings. This position helps prevent regurgitation and aspiration of the feeding. Positioning the client supine (Choice A) increases the risk of aspiration as it promotes reflux. Administering feedings over 10 minutes (Choice B) does not directly reduce the risk of aspiration. Placing the client in a lateral position after feedings (Choice D) does not address the risk of aspiration during the feeding process.

5. In approximately what percentage of cases is the prevalence seen?

Correct answer: A

Rationale: The correct answer is A, Type 1 Diabetes. The prevalence of Type 1 Diabetes is seen in approximately 5% to 10% of cases. This statement highlights a key epidemiological characteristic of Type 1 Diabetes. Choice B, Type 2 Diabetes, is incorrect because the prevalence mentioned does not align with Type 2 Diabetes, which has a much higher prevalence in the general population. Choices C and D are not relevant to the question and can be disregarded.

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